Provider Demographics
NPI:1255472940
Name:LUSTGARTEN, JONATHAN HENRY (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:HENRY
Last Name:LUSTGARTEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 STATE ROUTE 36
Mailing Address - Street 2:SUITE 330
Mailing Address - City:WEST LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07764-1454
Mailing Address - Country:US
Mailing Address - Phone:732-222-8866
Mailing Address - Fax:732-870-6432
Practice Address - Street 1:121 STATE ROUTE 36
Practice Address - Street 2:SUITE 330
Practice Address - City:WEST LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07764-1454
Practice Address - Country:US
Practice Address - Phone:732-222-8866
Practice Address - Fax:732-870-6432
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA06243100207T00000X
NY199245207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G12918Medicare UPIN